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Gastroparesis and Dumping Syndrome: Current Concepts and Management

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Gastroparesis and Dumping Syndrome: Current Concepts and Management Journal of Clinical Medicine Review Gastroparesis and Dumping Syndrome: Current Concepts and Management Stephan R. Vavricka 1,2,* and Thomas Greuter 2 1 Center of Gastroenterology and Hepatology, CH-8048 Zurich, Switzerland 2 Department of Gastroenterology and Hepatology, University Hospital Zurich, CH-8091 Zurich, Switzerland * Correspondence: [email protected] Received: 21 June 2019; Accepted: 23 July 2019; Published: 29 July 2019 Abstract: Gastroparesis and dumping syndrome both evolve from a disturbed gastric emptying mechanism. Although gastroparesis results from delayed gastric emptying and dumping syndrome from accelerated emptying of the stomach, the two entities share several similarities among which are an underestimated prevalence, considerable impairment of quality of life, the need for a multidisciplinary team setting, and a step-up treatment approach. In the following review, we will present an overview of the most important clinical aspects of gastroparesis and dumping syndrome including epidemiology, pathophysiology, presentation, and diagnostics. Finally, we highlight promising therapeutic options that might be available in the future. Keywords: gastroparesis; dumping syndrome; pathophysiology; clinical presentation; treatment 1. Introduction Gastroparesis and dumping syndrome both evolve from a disturbed gastric emptying mechanism. While gastroparesis results from significantly delayed gastric emptying, dumping syndrome is a consequence of increased flux of food into the small bowel [1,2]. The two entities share several important similarities: (i) gastroparesis and dumping syndrome are frequent, but also frequently overlooked; (ii) they affect patient’s quality of life considerably due to possibly debilitating symptoms; (iii) patients should be taken care of within a multidisciplinary team setting; and (iv) treatment should follow a step-up approach from dietary modifications and patient education to pharmacological interventions and, finally, surgical procedures and/or enteral feeding. Most importantly, the two diagnoses have to be considered by one of the treating specialists, regardless of whether this is the endocrinologist, nutritional specialist or gastroenterologist, when symptoms are present. Pre-test probability based on comorbidities (such as diabetes in case of gastroparesis or surgical history for dumping syndrome) together with the presence of typical symptoms should lead to a high degree of clinical suspicion. However, for both disorders, diagnostic evaluations should follow in order to confirm the diagnosis before initiation of treatment. Firstly, because treatment options might be invasive and require proper diagnostic evaluations beforehand. Secondly, several differential diagnoses might show a similar presentation. Such diagnoses are peptic ulcer disease, gastric cancer, celiac disease, abdominal angina for gastroparesis, anastomotic ulcers, internal herniation and gallbladder disease for early dumping syndrome and insulinoma, surreptitious use of glucose-lowering medication for late dumping [2–5]. In the following review, we will present an overview of the most important clinical aspects of gastroparesis and dumping syndrome including epidemiology, pathophysiology, presentation, diagnostics and treatment. Finally, we highlight promising therapeutic options that might be available in the future. J. Clin. Med. 2019, 8, 1127; doi:10.3390/jcm8081127 www.mdpi.com/journal/jcm J. Clin. Med. 2019, 8, 1127 2 of 14 2. Definitions and Epidemiology Gastroparesis and dumping syndrome are frequent, but their prevalence and incidence vary depending on definitions and studied populations. Therefore, heterogenous results have been reported in the literature. 2.1. Gastroparesis Gastroparesis is a syndrome characterized by an objectively delayed gastric emptying in the absence of a mechanical gastric outlet obstruction and the presence of cardinal symptoms such as early satiety, postprandial fullness and nausea-vomiting [6]. The prevalence of gastroparesis in the general population is uncertain. A wide range in different at-risk populations has been reported. In addition, gastroparesis is likely significantly under diagnosed. While an epidemiological study from Olmsted county revealed a prevalence of 24.2/100,000 for definite gastroparesis and 50.5/100,000 for definite, probable or possible gastroparesis [7], prevalence might be as high as 1.8% [8]. Patients with type 1 diabetes are at particular risk. Here, 10-year incidence rates of 5.2% have been reported (in contrast to a rate of 1% for type 2 diabetes and 0.2% for non-diabetic patients [9]. Other studies demonstrate even higher rates for diabetics with 58% for type 1 and 30% for type 2 [10,11]. However, most of the performed studies have a considerable selection bias with inclusion of patients from tertiary referral centers only. Still, there might be a large proportion of undetected gastroparesis patients, because either the patient does not seek medical attention or the treating doctors are reluctant to evaluate symptoms and/or further diagnostics. The incidence of postsurgical gastroparesis after gastrectomy is approximately 0.4% to 5.0% [12]. Overall, the incidence of gastroparesis after surgery depends on the surgical procedure and the surgical site. In the early postoperative period after pylorus-preserving pancreatoduodenectomy, postsurgical gastroparesis occurs in up to 20% to 50% of patients [12]. In one study, 67% of patients who underwent pancreatic cancer cryoablation were found to suffer from gastroparesis [13]. There seems to be a gender-specific differences with women accounting for up to 70% of the affected population. Interestingly, elderly patients (>65 years old) are at particular risk [14]. 2.2. Dumping Syndrome Dumping syndrome is a frequently encountered postsurgical complication that can be divided into an early and late subtype [2]. Alterations in gastric anatomy after esophageal, gastric and bariatric surgery result in rapid passage of food into the small intestine, which leads to early gastrointestinal and vasomotor symptoms (within 1 h) and late hypoglycemia (1 to 3 h after meal ingestion) [15,16]. Reliable population-based prevalence data for dumping syndrome are still lacking. As of yet, the frequency of postsurgical dumping syndrome is estimated at 25%–50% with 5 to 10% of patients experiencing a severe disabling form [17]. These rates vary depending on type of surgery prodecure [2]. While 20% of patients suffer from symptoms of dumping syndrome after vagotomy and pyloroplasty, these rates rise to 40% after Roux-en-Y bypass and sleeve gastrectomy, and peak at 50% after esophagectomy [18–22]. The incidence and prevalence of dumping syndrome has been increasing due to the current obesity epidemics and the consecutive climb in gastric bypass surgeries [23]. Early dumping represents the most common type, while isolated late dumping is observed in only 25% [2,22]. Due to considerable overlap in clinical presentation it is, however, sometimes difficult to differentiate between the two and co-occurrence is frequently encountered. 3. Pathophysiology and Clinical Presentation The occurrence of cardinal symptoms after ingestion of a meal in a patient with high pre-test probability should rise suspicion for the presence of gastroparesis or dumping syndrome. The symptoms per se are rather non-specific and might occur with many other diseases. However, the existence of risk factors such as diabetes for gastroparesis or bariatric surgery for dumping makes the diagnoses more likely (Tables1 and2). J. Clin. Med. 2019, 8, 1127 3 of 14 3.1. Gastroparesis Several aspects contribute to a delayed gastric emptying in gastroparesis patients. Among these are extrinsic denervation of the stomach, impaired inhibitory input to smooth muscles due to loss of nitric oxide in enteric nerves, loss of interstitial cells of Cajal (ICC, “pacemaker cells), smooth muscle atrophy and altered function of immune cells [1]. ICC generate electrical slow waves in the stomach, and disrupted ICC networks and gastric dysrhythmias have been associated with gastroparesis [24]. For details see Figure1. The most frequent etiologies are diabetes and surgery [ 25]. In a high proportion of patients, the underlying cause remains unknown (so called idiopathic gastroparesis) [25]. This form is found in particular in younger women and appears to be associated with viral infection (in up to 20%) [26–28]. Less frequent etiologic factors are Parkinson’s disease, amyloid, tumors (paraneoplastic gastroparesis), scleroderma, or mesenteric ischemia [29]. Importantly, medication-induced gastroparesis has to be considered in all patients. Typically here are opioids, ciclosporine, anticholinergics and glucagon-like peptide 1 (GLP1)-agonists [30–32]. The latter should be particularly suspected in diabetic patients before considering the gastroparesis to be caused by diabetes and poor control of blood glucose. From a clinical perspective, the simplest classification of gastroparesis is into the two categories diabetic vs. non-diabetic. Delayed gastric emptying can be observed in 28% to 65% of unselected patients with diabetes [33,34]. Patients with type 1 diabetes have a higher incidence of gastroparesis as compared with type 2 (5.25 vs. 1%) and an earlier age at onset [7,9,29]. Type 2 diabetics, however, have more serious symptoms. Gastroparesis in diabetic patients usually occurs 10 years after the onset of diabetes and it parallels other forms of diabetic microvascular disease, including neuropathy
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